Wiki DX for labs ordered during preventive visit

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KScoderTN

KScoderTN

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Office discussion:

Patient is schedule for their annual well/preventive visit. No abnormal findings. Doctor simply puts Z00.00 on the order for the lab.

Do you query the physician to have them specify diagnosis/ICD -10 since Z00.00 is not a covered diagnosis for the specific labs that are covered under preventive (example Medicare patients PSA/Z12.5, lipid/ Z13.6, diabetes/Z13.1 ) or do you add these codes as coders, inferring from the record?

Thank you for your time in advance.
 
The PSA is pretty self-explanatory but I would not assume a lipid profile is necessarily done to screen for cardiovascular disease. What test is being done for the diabetes? I would not assume this is for diabetes either.
 
When you say the Z13 codes for lipids, diabetes, these are screening codes and are fine if the test is for screening, if the patient has th condition and is taking meds for the condition then it is no screening, it is drug monitoring,(Z51.81) followed by the Z79.- code for the type of drug. If there is no screening and there is no drug monitoring the it is routine prev native and may not be covered.
 
The question is that since the doctor is using Z00.00 on the lab order for ALL labs & no other diagnosis is being offered, do you query the physician to request that he specify each lab is for screening & encourage them to document the specific codes for the screening?
 
What does the note state? The provider does not need to supply the codes only he documentation. If the note does not state whether the tests are screening or for drug maintenance follow up, then he needs to be queried to add this to the note.
 
The note says the patient was scheduled for an annual well visit & the documentation is worked up accordingly. Then the doctor lumps all the testing under the diagnosis of Z00.00, which the doctor sees as an all encompassing screening code. No issues are found, patient is there for a well visit. Does that make more sense?
 
Then you will have no choice but to submit the labs this way. If there is nothing to tell you that due to the Lipitor a liver panel is ordered or due to the risk for diabetes a screening is ordered then there is no way to know what the provider is thinking when he writes the order.
 
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